<html>
<head>
<link href="//maxcdn.bootstrapcdn.com/bootstrap/3.3.1/css/bootstrap.min.css" rel="stylesheet">
</head>
<body>
<div class="container-fluid">
  <div class="row">
    <div class="col-md-4">
      <h1>Search</h1>
      <form action="/" method="POST">
        <div class="form-group">
          <label>target_county_ansi_code</label>
          <input type="text" name="target_county_ansi_code" class="form-control" placeholder="For example: 0000001">
        </div>
        <div class="form-group">
          <label>target_url</label>
          <select class="form-control" name="target_url">
            <option value="http://www.smcare.org">http://www.smcare.org</option>
          </select>
        </div>
        <div class="form-group">
          <label>target_year</label>
          <input type="text" name="target_year" class="form-control" placeholder="For example: 2004">
        </div>

        <div class="form-group">
          <label>target_record</label>
          <input type="text" name="target_record" class="form-control" placeholder="For example: 000001">
        </div>

        <div class="form-group">
          <label>results_url</label>
          <input type="text" name="results_url" class="form-control" placeholder="Default to: http://www.tma-3.com">
        </div>

        <div class="form-group">
          <label>email_address</label>
          <input type="text" class="form-control" placeholder="">
        </div>

        <div class="form-group">
          <label>email_subject</label>
          <input type="text" class="form-control" placeholder="">
        </div>
        
        <button type="submit" class="btn btn-default">Submit</button>
      </form>
    </div>
  </div>
</div>
</body>
</html>